Safety net for high-risk pregnancies

Childbirth-related expenses represent the highest health costs for many companies, and premature pregnancies consume 60% of neonatal healthcare dollars. Couple those facts with the sober statistic that more than 12% of U.S. pregnancies end prematurely, and it’s clear how the March of Dimes reported the preterm birth cost was at least $26.2 billion, or $51,600 for each preterm infant, in 2005.

According to the March of Dimes, the average length of a hospital stay for a term infant is 1.5 days, but preterm infants spend an average of 13 days in the hospital. In a preterm child’s first year alone, the average medical cost, including inpatient and outpatient care, is $32,325, about 10 times greater than for term infants ($3,325).

High-risk pregnancies are not only short-term cost drivers, but premature babies can suffer from long-term (sometimes lifelong) health issues.

With that in mind, two companies have implemented programs that provide a safety net for those most at risk.

Matria Healthcare

Matria Healthcare has found that a comprehensive outpatient management program for women with preterm labor saves money through fewer ER visits, averted antenatal hospitalizations for the mother, and fewer neonatal ICU (NICU) admissions for the newborn.

“What our program is trying to accomplish is to get that pregnancy further along so that the baby is born in a later gestation stage so therefore their morbidity and their cost for you, the health plan, or the society at large is reduced,” says Gary Stanziano, MD, senior vice president at Matria. He is a coauthor of “When More Care Can Equal Less Cost: Remote Health Monitoring of the Pregnancy Experiencing Preterm Labor,” a study presented at the 2007 Disease Management Leadership Forum in Las Vegas.

The Marietta, GA–based DM company reviewed the data from 34,099 high-risk pregnancies enrolled in its comprehensive outpatient preterm labor management services between January 2000 and December 2005. Researchers compared those numbers to a control group of the same singleton, twin, and total number of high-risk births, which they collected from data published in several clinical articles.

What Matria found did not surprise its researchers: The outpatient program that prolongs pregnancy averts hospital visits and saves money. In fact, Matria claims a 3:1 ROI when researchers compared the outpatient program to the control group.

“The ROI is one piece of it, but with these types of pregnancies, it’s the impact of not just the cost of the hospitalization of the mom and the immediate costs for hospitalization of the baby in a NICU, but there is also the long-term and disability costs that have to be borne by our healthcare system,” says Stanziano.

The review found fewer antenatal hospital days and admissions and shorter stays in the NICU for the monitored group. (See the chart on p. 11 of the PDF of this issue.)

Companies that implement a high-risk pregnancy program should expect to invest money in the front end with the understanding that longer pregnancies, and averted hospitalizations and ER visits, will save money in the long run. In Matria’s case, the outpatient program (nurses and equipment) cost more than $200,000, and there were no added outpatient costs in the control group. Overall, researchers reported Matria saved $12,597 per pregnancy during the study period.

Matria’s high-risk pregnancy program has two components. One is in the home. High-risk obstetrical nurses visit the home and educate the expectant mothers on the services prescribed by their physicians, including preterm labor signs and symptoms, premature birth facts, and lifestyle issues. The nurses also train the expectant mothers on the home biometric devices that are part of the program, which the expectant mothers utilize twice a day to allow the nurses to track uterine activity. (The nurses also communicate with the patient’s doctor via weekly written reports of the biometric data.)

“What our program does is it follows her after that episode, and we watch her at home, the nurses watch her at home, access her daily via the telephone, and monitor the uterine activity so we can have early detection if there is a problem,” says Niki Istwan, RN, coauthor of the study and director of clinical research at Matria.

The other section of the program is a 24/7 nurse line. This allows expectant mothers to call with questions, and more importantly, if a patient experiences contractions, she calls the nurse line rather than rush to the hospital. The uterine activity is transmitted from the biometric device over the phone line to the nursing call center where it is evaluated, usually within 45 minutes. The nurse then instructs the expectant mother whether a trip to the hospital is warranted.

The 1,400 high-risk OB nurses who work in the Matria program are usually ex-labor and delivery nurses who have an expertise in complex cases. “You need the nurse, you need the machine, and you need the experience. You need all the information you can get,” says Istwan.

Stanziano says Matria’s outpatient program works especially well in the Medicaid population. “I think part of the reason is because they are talking to a nurse who is committed to that pregnancy and that woman’s outcome. That sector today in our society is blown off a lot of the time. There is a bonding that occurs with the nurse,” says Stanziano.

Istwan disagrees that a pregnancy must reach full term in order to be deemed successful. Any pregnancy prolongation benefits the child. “You’re trying to get to term, but every week is a success . . . Any week you can prolong a pregnancy, you are going to decrease costs and neonatal morbidity.”

The Assist Group

The Assist Group in Lakewood, CO, is another example of a company that has created a maternal-newborn and child care management program aimed at improving clinical outcomes while lowering costs. Newborn conditions, such as prematurity, low birth weight, and respiratory distress syndrome are among the highest-cost catastrophic conditions, according to The Assist Group. “Technology and medical improvements are helping more and more fragile infants survive,” says Rose Bemis-Heys, executive vice president of strategic development at The Assist Group. “These developments are not only increasing NICU length of stays and costs but long-term costs that stretch into childhood and sometimes adulthood.”

The Assist Group’s response to the issue is CareAssist, a comprehensive maternal-child care management program. The program is designed to manage the high-risk pregnancy, the newborn admitted to the NICU, and, as necessary, any complications extending to the pediatric period.

High-risk pregnancy management can optimize the pregnancy outcome, avoiding or reducing the NICU length of stay and childhood problems. When an infant is admitted to the NICU, the CareAssist program is already in place and working to improve the infant’s outcome from day one. CareAssist can assure continuity of care after discharge from the NICU for any scheduled surgeries, procedures, or other pediatric issues. The company’s program includes several innovative features:

Predictive modeling that uses a system that draws from a database containing nearly 120,000 newborn records that estimates each infant’s length of stay and costs

Acuity-based resource allocation assuring that the right resources are assigned to each case based on the patient’s clinical and psychosocial complexity

Family preparedness that includes an expert nurse care manager who works with family members to involve them in decision-making and provides them with education and resources up to 14 days after discharge

Financial claim review in which CareAssist documents the changes in levels of care and reviews the billed charges to ensure that they reflect the care provided

The nurse care manager coordinates the care team—providers, family, and payer—and the flow of information and decision-making. This individual is also available for the family to answer questions and serves as an expert and advocate for the family. The physician consultant works directly with the attending physician. The consultants are expert neonatologists and maternal fetal medicine specialists. Bemis-Heys says this aspect of the program is crucial.

Managed care programs often meet resistance dealing with physicians, but Bemis-Heys says that has largely not been the case for CareAssist. The reasons are that The Assist Group’s specialists are leaders in their area of specialty and they provide recommendations (rather than demanding changes in care) that are supported by evidence-based medicine.

The family preparedness aspect of CareAssist spans the continuum from pregnancy to bringing the infant home. This can include making sure the facility where the patient delivers has the appropriate level of NICU care so that the child isn’t born in one facility and then transported to a hospital with a higher level of care. It also includes helping parents cope with a fragile newborn. The company uses a program called COPE, which has been demonstrated in a randomized controlled clinical trial to reduce NICU length of stay and decrease depression, stress, and anxiety for parents of premature infants.

The financial claim review is a way to assure payers that they are being billed properly for the care provided. CareAssist offers a preliminary review of the claims. If discrepancies are noted, a full bill review called a “Forensic Review” is recommended. Bemis-Heys says The Assist Group’s Forensic Review solution can save payers on average 20% of billed charges.

Without taking the claim review savings into account, a recent evaluation showed CareAssist’s impact on costs.

They concluded CareAssist’s ROI was 3:1, or three dollars saved for every dollar spent on care management. There was an average reduction in NICU length of stay of 15%. Bemis-Heys says the ROI comes from ensuring optimal care and family preparedness. Including high-risk pregnancy management can even add more to the savings as “every week in the womb helps improve the newborn outcome and reduce costs,” says Bemis-Heys.